MA 112 – Medical Records and Doucmentation – Flashcards
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The patient owns the medical record
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False
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An aggregate of activities designed to ensure adequate quality is called, quality control
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True
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Subjective information is that which the physician observes during the physical examination of the patient
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False
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A standard, nationwide rule must be followed in establishing a records retention schedule
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False
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Conditioning paper involves including a mark that indicates the papers are ready for filing
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False
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The three basic filing methods are alphabetic, numeric and alphanumeric
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True
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Numeric filing is a direct filing system
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False
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A provisional diagnosis is not a final diagnosis and usually is made before test results are recieved
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True
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When documents are added to a patient's chart, the most recent information should be placed on top
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True
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It is not necessary to keep a copy of a patient's consent form in the chart
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False
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Medical records offer protection to the physician during legal proceedings if they are accurate and complete
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True
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By legal definition, if it isn't charted, then it didn't happen
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True
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Only the physician owns the medical records
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False
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Numeric filing provides extra confidentiality to medical records
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True
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Color coding is used only for patients' records and not for business records
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False
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Whatever medical records system is used in a facility, it should first provide for easy retrieval of records, and it must work for the individual facility
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True
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All physician's currently use electronic health records
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False
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The computer based medical record as no disadvantages, whereas the paper based record has numerous disadvantages
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False
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The patients medical records should never leave the office
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True
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Which of the following is not a method of organizing a medical record
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Progressively
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Information the is gained by questioning the patient, or that is taken from a form is called ________ information
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Subjective
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Which of the following are not needed, when describing a patient's chief complaint
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How many family members are healthy
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A filing system in which an intermediary source of reference, such as a file card, just be consulted to locate specific files is called a _______ system
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indirect filing
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Releasing a record, with regard to filing it means
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placing a mark indicating that the item is ready for filing
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How would you properly index the name "Jill Freeman, M.D" for filing, if you had another patient with the same name but without the title
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Freeman, Jill M.D.
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How would you properly index the name "Amanda M. Stiles-Duncan" for filing
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Stilesduncan, Amanda M.
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Who is the legal owner of the information stored in a patient's record
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The physician or the agency where services were provided
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Continuity of care means;
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medical attention that continues smoothly form one provider to another so the patient receives the most benifit
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A legal instrument that authorizes a person to act as the agent of the grantor is called a
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power of attorney
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Which of the following are common types of filing equipment that is found in a medical office
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Rotary circular files,
Automated Files,
Lateral Files,
(all of the above)
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Which of the following is not an advantage of color coded filing systems
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Patient Charts can be found quickly,
It is easy to tell when a file has been misplaced,
Patient charts can be refiled quickly,
(all of the above)
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Which statement is not true regarding the reasons for keeping accurate medical records
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The patients family may want to examine the records an correct errors
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Which of the following is not objective information
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Family history
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What is the most important reason for telling the physician when a charting error is discovered later
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To protect the patient's health and well being
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Which statement is not accurate about correcting errors
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Draw two clear lines through the error
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Which of the following steps for records release is out of order
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Review the record release form for the patient's chart, and ask whether the person understands it
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The medical record should be released only with a
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written release from the patient
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Medical facilities should keep records on minors for how long
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Until the minor reaches the age of majority, plus 3 years
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Which of the following is not an advantage of a numeric filing system
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Filing activity is greatest when the system is initiated
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An informed consent form must address which of the following
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Risk and benefits of the procedure,
Reasonable alternatives to the procedure,
Risks and benefits of not performing the procedure,
(all of the above)
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The three stages of machine transcription do not include
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reviewing the dictated text with the patient
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When preparing a file for a new patient, the MA should
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Make sure the patient's name is spelled correctly,
Review the forms the patient filled out for completeness,
Copy the insurance card or make sure the insurance information is included,
(all of the above)
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An item used to provide space for the temporary filing materials is called a
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out folder
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The most efficient type of medical record is the
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computer based medical record
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The method of filing in which one report is laid on top of the older report, resembling a roof , is called
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shingling
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HIPAA recommends that physicians keep the records on patients for at least
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HIPAA does not recommend a number of years
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Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____ files
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closed
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The MA should consider which of the following when selecting filing equipment
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Fire protection,
Cost of space and equipment,
Confidentiality requirements,
(all of the above)
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A strong, highly glazed composition paper or heavy card stock is called
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pressboard
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The process of moving an active file to inactive status is called
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purging
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The physical medical record belongs to the
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physician or provider
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A correction to a medical record can be made by
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drawing a line through the entry and writing the correct information
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The "E" entry in SOAPER charting method means
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education
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The "R" entry in SOAPER charting method means
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response
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The preferred filing method for a physicians office is
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the one most preferred by the staff
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A temporary or transitory file might be used for a
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Patient from another area who is only in the city for a short while,
Letter requesting a reprint from a magazine,
Letter requesting information about a product or drug,
(all of the above)
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The newest component used today to complete transcription and authenticate records is ______
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Voice recognition
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Transcription tasks might be outsourced to
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Individuals working at home,
A business that offers transcriptions services,
A hospital employee who does extra transcription work,
(all of the above)
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Who ultimately decides whether a medical record can be released
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The patient
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Which of the following names should be filed first?
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A) = in indexing nothing comes before something
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Which of the following name should be filed first
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MacAllister
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Which of the following names should be filed first
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William Jones
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Which of the following names should be filed first
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A Roberts Production
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Which is the correct way to designate this patient's name in filing?
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Doe, Mary Jones (Mrs. John L.)
